8. TEACHING POINTS: MANAGEMENT OF EARLY PREGNANCY LOSS

Purpose: To practice management of challenging situations in early pregnancy loss, and consider care continuity with one patient. Note: gender specific language is used for this case.

A 25-year-old woman you have been seeing for 5 years presents for an urgent visit. Her past history includes irregular periods, which you have managed with OCPs. She reports not having had a period for 7 weeks, and now is having abdominal cramping and moderately heavy bleeding, up to a pad every hour. Her urine hCG is positive.

If the hCG is above the discriminatory zone, an ultrasound is important to determine the location of the pregnancy unless the patient has a previously diagnosed IUP or EPL. Alternatively, serial hCGs can be obtained.

If initial value is below the discriminatory zone, serial hCGs can be obtained.

If ultrasound is non-diagnostic, proceed with first hCG now. Or if initial value is above the discriminatory zone, proceed with a second hCG in 48 to 72 hours,.

If the pregnancy is undesired, the patient can choose to proceed directly to uterine aspiration (without waiting for hCG results). This enables the patient to receive treatment without delay, and may enable immediate confirmation of IUP vs. ectopic (if membranes and villi are confirmed).

How would you counsel her while waiting for results?

The uncertainty of waiting for results can be stressful. Keep her fully informed.

Inform that in > 50% of bleeding cases in the first trimester, the pregnancy continues.

Ask if she has someone who can support her in this potentially difficult time.

If an ultrasound reveals an intrauterine pregnancy with the presence of fetal cardiac activity, how would you discuss the result with her?

Over 85% of women with fetal cardiac activity on ultrasound go on to have full term pregnancies. You can initiate or refer for routine prenatal care if desired.

Mention a lack of evidence to support limiting activities, being sensitive to anxieties.

If bleeding or cramping continues or begins again, repeat the evaluation.

Determine Rh status, and administer Rhogam as appropriate.

If a termination is desired, you can offer abortion services or a referral. Return to Exercise

The same woman comes in one year later. She had a normal delivery following the previous threatened abortion, and never restarted her OCPs. She recently began a new relationship, and has been using condoms intermittently. She began having vaginal bleeding about 5 days ago, and it is now decreasing. Her last menstrual period was 8 weeks ago. Her urine pregnancy test is positive. She brings in tissue and you see gestational sac and chorionic villi.

How would you proceed with evaluation?

The foremost question of ectopic pregnancy is answered by the finding of gestational sac and chorionic villi, except in the rare case of heterotopic pregnancy.

The history is consistent with a spontaneous abortion, likely complete given her decreasing bleeding.

As with all cases, it is essential to assess for hemodynamic stability, or need for evaluation for anemia or infection. These concerns would prompt a physical exam and labs, including Rh status.

If her bleeding and cramping are ongoing, an ultrasound is optional to evaluate the contents of the uterus.

If the overall picture is consistent with an incomplete abortion, the patient should be offered expectant, medication, or aspiration management.

How would you approach her initially with these results? How would you answer her if she asks, “Was this miscarriage my fault?”

Avoid preconceived notions about her feelings about this pregnancy. For example, even though she has a small infant at home, do not assume that this pregnancy was undesired.

Tell her an early pregnancy loss is common, unlikely to occur in subsequent pregnancies, and not a woman’s fault, even though many women feel guilty.

After discussing the results, await her response and consider open-ended questions about her expectations, such as “How are you feeling about what is happening?” or “How do you feel about what I have told you?”

What information would you provide about how this event will affect her ability to carry subsequent pregnancies to term?

Early pregnancy loss is common, and in the majority of cases one or two previous EPLs does not predict subsequent pregnancy loss. Studies of women with 3 EPLs found that over half were later able to carry a pregnancy to term.

Encourage a follow-up visit to discuss ways to minimize problems with subsequent pregnancies, such as minimizing smoking and alcohol intake and to gain control of chronic medical conditions.

Following three consecutive EPLs (or two for patients with advanced age), it is appropriate to initiate evaluation for conditions such as chromosomal abnormalities, anatomic problems, luteal phase defects, or immunologic disorders such as anti-phospholipid syndrome, that may contribute to recurrent pregnancy loss.

What other evaluation or management would you initiate? When can she attempt to conceive again

Administer Rh immune globulin as appropriate.

Address contraceptive goals, methods and use. In most cases the woman can attempt to conceive when she feels emotionally and physically ready.

The same patient presents to you three years later, at 29 years of age. She is now in a long-term relationship with one partner, and has been attempting to become pregnant. It has been 5 weeks since last menstrual period, urine hCG is positive, and she has been spotting for 6 days, without passage of tissue or pain. She is tearful and distraught, as this pregnancy is desired.

Does she need an ultrasound in this case? How would you assess her without the use of ultrasound?

It is unclear if this is an IUP or if the pregnancy is viable.

With a stable patient, you can either obtain an US or serial hCG levels.

Given her distress, an US (if available) may provide answers more quickly.

If unavailable, begin evaluation with a physical examination and hCG level.

Examination should assess for hemodynamic stability, an open os and/or tissue, uterine size, and assessment for adnexal masses or tenderness.

Inform her of the possibility of ectopic pregnancy, and give ectopic precautions.

She should return in 2 days for a second hCG level.

On examination, you find a closed cervical os, no gestational tissue, and a non-tender uterus consistent with 5-week gestation size without adnexal tenderness or enlargement. You are able to obtain a transvaginal US, which shows an intrauterine fluid collection measuring < 4mm with no yolk sac present. How do you interpret these results? What are the next steps in her evaluation?

The location of your patient’s pregnancy is still undetermined at this point.

Differential diagnosis includes:

IUP too early to be definitively diagnosed on US.

Ectopic with an intrauterine pseudosac.

EPL

When unable to clearly visualize a pregnancy on US in a stable patient, draw serial hCG levels.

In patients with desired pregnancies, diagnosis based on a more conservative, or slower, rate of increase is preferred, as it can help avoid misclassification of a desired IUP as an ectopic or EPL.

With a viable IUP, the change in hCG level over 2 days can range from an increase of just 35% to the traditionally expected doubling. Using an increase of > 53% in 2 days you will detect 99% of viable IUPs (Barnhart 2009).

For patients experiencing EPL, a decline in hCG level is expected. A decline of >50% in 2 days from last hCG supports a diagnosis of resolving PUL.Return to Exercise

A hCG level drawn at her initial evaluation is 1000. Repeat hCG level drawn two days later is 1300. How do you interpret these results? What are your next steps?

Based on her examination and initial hCG level, this patient could be experiencing EPL, ectopic pregnancy, or have an early IUP. Repeat her bimanual exam, to assess evolution in the clinical picture. Although her second hCG level increased, it did so by only 30%, which is less than expected for a viable IUP. A rise in hCG of less than 53% in 2 days suggests an abnormal pregnancy and should prompt intervention to distinguish an ectopic pregnancy from an EPL. For patients with a desired pregnancy, you may use a cut off of 35% in order to avoid misclassification of an IUP as an EPL or ectopic.

If this was a non-desired pregnancy, the following calculations could be used if diagnostic aspiration is negative for POC and you are considering ectopic management.

Initial hCG x expected % rise on day 2 = expected rise

1000 x 0.53 = 530

Initial hCG + expected rise = minimum expected 2nd hCG

1000 + 530 = 1530 (by day 2 should be > 1530)

If ectopic is not definitively excluded, continue to follow hCG levels. Due to overlap in levels, hCG levels must be correlated with the full clinical picture.

When the hCG level does not increase as expected for an IUP or decrease as expected for EPL, adding a third hCG level on day 4 or 7 increases the sensitivity for detecting ectopic pregnancy.

If EPL is confirmed and completed, what kind of support may be of use to her?

Reminding her that EPL is not her fault may address her unspoken fears.

She has now had 2 spontaneous abortions, so she has a > 70% chance of successful future pregnancy. Further work-up is recommended at this time, as described in Exercise 8.2.c.

Useful resources for support include her family and community, or counseling resources such as a miscarriage support group.

With desired pregnancies, giving space to grieve is crucial. You can encourage her to acknowledge her to take special time or find a grieving practice. Set up additional follow-up appointments as needed.